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COVID-19 Vaccine Pre-registration- Facilities
DISCLAIMER: Filling out this form does not guarantee your chances of getting the COVID-19 vaccine. Once we have more information, we will contact you personally. Thank you for your interest and stay safe.
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* Indicates required question
Email
*
Your email
First and last name of Contact Representative
*
Your answer
Facility Name
*
Your answer
Facility Type (LTC, SNF, Group Home, etc.)
*
Your answer
Full Address of Facility
*
e.g. "1919 W North Ave, Milwaukee, WI 53206" "Homeless" if you are currently experiencing homelessness
Your answer
Phone Number
*
Full phone number with area code. e.g. 414-374-0000
Your answer
A copy of your responses will be emailed to the address you provided.
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